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Surgery EORE > Cardiovascular > Flashcards

Cardiovascular Flashcards

1
Q

Epidemiology thoracic aortic aneurysm

A

6th-7th decade MALE w/ hx HTN

Ascending aortic aneurysm = MC (60%) - 2/2 cystic medial necrosis

Descending aortic aneurysm (40%) - 2/2 atherosclerosis

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2
Q

CP thoracic aortic aneurysm

A

MC asymptomatic

If compression of local anatomy - back pain, flank pain, abd pain

Cold foot = thromboembolism preventing blood flow to area

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3
Q

PE thoracic aortic aneurysm

A

Commonly normal

Rupture = hemorrhagic shock (tachy, dec BP)

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4
Q

Dx thoracic aortic aneurysm

A

CT ANGIOGRAM = best imaging study

MRI if cannot receive contrast for CTA (renal fxn, preggers)

CXR may be first indication of aneurysm if large enough (widened mediastinum)

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5
Q

Treatment aortic aneurysm

A

Medical prevention:

  • Beta-blockers (esp if a/w marfan synd) - decreased HR = limits rate of expansion
  • ACEI/ARB - limit expansion

Surgery indications - catheter guided stent graft placement (closed endovascular repair) IF:
Symptomatic
Ascending > 5.5cm
Descending >6.5 cm

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6
Q

Abdominal aortic aneurysm risk factors (6)

A 
Age > 60
HTN
Smoking
Atherosclerosis
Other aneurysms
HLD
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7
Q

CP AAA

A

**ASX until rupture
Rupture = back pain, flank pain, groin pain

Sudden cold or blue distal extremities - thromboembolism = limb ischemia

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8
Q

PE AAA

A

Vitals normal until rupture - then hemorrhagic shock (tachy, low BP)

ABD: Rupture = palpable pulsatile mass, distension, tenderness

Skin: Rupture = Cullen’s sign (periumbilical bruising) or Turner’s sign (bruising on flank/back)

Sudden cold or blue extremity 2/2 limb ischemia or thromboembolism

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9
Q

Indications for US to screen for AAA (4)

A

ABD ultrasound indicated for:
[1] Men 65-74 YO w/ hx smoking
[2] Siblings or offspring w/ AAA
[3] Pt w/ presence of thoracic AA or peripheral arterial aneurysms
[4] Pt w/ hypermobility syndromes (marfan, ehler-danlos)

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10
Q

Dx AAA

A

Abdominal US = BEST IMAGING STUDY

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11
Q

What size to we start following AAA closesly? At what size is intervention required?

A

Follow closely > 3cm
Intervene > 5-5.5 cm
(at risk for rupture)

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12
Q

Repair options AAA

A

Open surgery vs closed endovascular repair - closed preferred (lower short term morbidity)- based on anatomy & comorbidities

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13
Q

Follow up s/p repair of AAA

A

Long term surveillance w/ CTA or MRA after endovascular repair

If ruptures before scheduled surgery - has 50% mortality during surgery

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14
Q

Aortic dissection risk factors (6)

A

Review: dissection = tear in intima separation of intima from media = false lumen

RF: 
[1] HTN
[2] Atherosclerosis
[3] Collagen disorder
[4] Aortic valve replacement
[5] Aortic aneurysm
[6] Cardiac catheterization
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15
Q

CP aortic dissection

A

Sudden severe sharp or tearing CP in posterior chest or back pain

HTN

Wide pulse pressure

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16
Q

Dx aortic dissection

A

Essentials for dx:
[1] clinical presentation c/w dissection
[2] evidence of dissection via imaging:
- CXR - probs the initial study done - will show widened mediastinum
- CTA - BEST IMAGING STUDY

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17
Q

Initial management of dissection

A

HR and BP control w/ esmolol, pain relief w/ morphine

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18
Q

Management of acute Stanford type A dissection

A

Stanford type A dissection = dissection starts at ASCEND-ing aorta = SURGICAL EMERGENCY

Endovascular (closed) repair vs open repair

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19
Q

Management of acute Stanford type B dissection

A

Stanford type B dissection = one that starts in descending aorta - less serious than type A

Try to medically manage first - esmolol, pain relief (morphine)

Indications for surgery - aortic rupture, end organ ischemia, continued hemorrhage into pleural or retroperitoneal space, continued HTN/pain despite management, early false lumen expansion, large single entry

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20
Q

Long term management of aortic dissection

A

Long term medical therapy - minimize aortic wall stress w/ lifelong BB therapy and goal BP <120/80

Serial imaging: 3mo - 6mo- 12mo then q1-2 years after

21
Q

Indications for reoperation after aortic dissection repair

A

Recurrence of dissection
Aneurysm formation
Leakage at anastomosis or stent

22
Q

Sources of arterial EMBOLI in acute limb ischemia 2/2 arterial occlusion?

Sources of arterial THROMBUS?

A

Arterial EMBOLI 2/2
Afib, MI, endocarditis, valvular disease, prosthetic valves

Arterial THROMBUS 2/2: vascular grafts, atherosclerosis, hypercoagulable state, entrapment syndrome, arterial trauma

23
Q

MC vessels affected by arterial thrombus/emboli

A

Femoral 28%
Popliteal 17%

Arm 20%
Aortoiliac 18%

24
Q

Risk factors acute limb ischemia 2/2 arterial occlusion

A 
Afib
Recent MI
DVT
Arterial trauma
Large vessel aneurysm

RF of aortic dissection ([1] HTN [2] Atherosclerosis [3] Collagen disorder [4] Aortic valve replacement [5] Aortic aneurysm [6] Cardiac catheterization)

25
Q

CP acute limb ischemia 2/2 arterial occlusion (6 P’s of limb ischemia)

A

CP depends on course of vessel occlusion, location, and presence or absence of collaterals for blood supply

6 P’s:
Pain, pallor, paralysis, pulselessness, poikilothermia, paresthesia

26
Q

After how many hours does arterial occlusion result in irreversible damage?

A

After 6 hours

27
Q

Dx acute limb ischemia 2/2 arterial occlusion

A

History and PE

Ankle brachial index testing - pressure in foot/pressure in arm (foot normally higher than arm).
Nl value 1.0-1.4. 0.8-0.9 = some arterial dz. 0.5-0.8 = moderate arterial disease, <0.5 = severe arterial disease

Vascular imaging (revascularization may supersede need for imaging study)

28
Q

Indications for ABI (ankle brachial index) testing for PAD (peripheral arterial disease) & when to refer/intervene based on results

A

Indications:
Anyone > 70 YO
Every smoker > 50 YO
Every diabetic > 50 YO

Ankle Brachial Index Results:
Nl value 1.0-1.4
0.8-0.9 = some arterial dz - modify risk factors

  • *0.5-0.8 = moderate arterial disease
  • *<0.5 = severe arterial disease

Refer anyone < 0.9 w/ moderate arterial disease or severe arterial disease to vascular specialist

29
Q

Treatment acute limb ischemia 2/2 arterial occlusion

A

Emergent or urgent revascularization -

Anticoagulation w/ IV heparin

Thrombolytic therapy

Thrombectomy, embolectomy

Endovascular surgery - angioplasty or stent placement

Open surgical intervention

    • limb loss rate = 30%
  • *Mortality rate = 20%
30
Q

Follow up care after treatment of acute limb ischemia 2/2 arterial occlusion

A

Post-revascularization, must look into the cause of the clot

31
Q

Chronic venous disease pathophysiology

A

Inadequate muscle pump function, incompetent

venous valves, elevated venous pressure

Venous pooling → edema → ischemia

32
Q

Chronic venous disease types (3)

A

[1] Telangiectasia - dilated sm superficial veins = MOST COMMON FORM of chronic venous disease

[2] Varicose veins - dilated, tortuous superficial veins (MC greater saphenous)

[3] Chronic venous insufficiency - edema, skin changes, ulceration

33
Q

CP Chronic venous disease

A

Leg pain, heaviness, swelling, muscle cramps, tightness, irritation, discoloration, bleeding from varicose veins or telangiectasia

34
Q

PE Chronic venous disease

A

Pitting edema w/ dorsal pedal hump

skin changes - lipodermatosclerosis of the skin w/ discoloration (brawny, hemosiderin color)

Ulcers - irregular borders w/ surrounding induration & significant change

35
Q

Dx Chronic venous disease

A

Venous duplex ultrasound - dx = retrograde flow > 0.5 s in duration (suggests venous reflux)

36
Q

Treatment Chronic venous disease

A

Compression therapy - compression stockings or unna bot w/ 20-30 mmHg compression

Stasis dermatitis - steroid creams

Surgery - slcerotherapy, phlebectomy or ligation, laser ablation or radiofrequency ablation

37
Q

Indications for surgical intervention Chronic venous disease (3)

A

[1] failure of conservative therapy
[2] bleeding from dilated veins
[3] phlebitis or thrombosis of superficial veins

38
Q

Types of surgical options (3) for chronic venous disease and indications for each

A

[1] Sclerotherapy - for <4mm diameter veins

[2] Phlebectomy or ligation

[3] Endovenous laser ablation or readiofrequency ablation - for chronic venous dz of great saphenous vein w /intact deep venous system

Summary: SCLEROTHERPY = SMALL VEINS ONLY

ABLATION FOR LARGE VEINS (great saphenous)

39
Q

When to refer person w/ Chronic venous disease to specialist

A

[1] significant saphenous vein reflux
[2] open wounds - send to wound clinic/specialist
[3] cosmetic concerns

40
Q

PAD: Claudication - RF

A 
Age
Smoking
Male
Family hx
Homocysteinemia
Metabolic syndromes
41
Q

PAD: Claudication - pathophys

A

Claudication = ischemic type pain with exercise (inc demand) due to supply/demand mismatch - relieved by rest

Atherosclerosis = MCC - fibromuscular dysplasia = renal artery stenosis, arterial embolism, vasculitis

42
Q

CP PAD: Claudication

A

Extremity pain
Claudication (exertional pain cuased by supply/demand mismatch)

Ischemic rest pain (worse dz)

Dependent rubor (purple/red color on dependent areas)

Non-healing wound or ulcer (no bl flow to site = no healing)

Skin discoloration

Erectile dysfunction (any pt w/ ED should be screened for PAD)

43
Q

PE PAD: Claudication

A

Smooth shiny skin, cool skin, pallor, cyanosis, mottling

Buerger test - leg elevated 30 deg x 30 sec - turn blue?

Lower extremity neuropathy
Dec/absent distal pulses
Bruits

Dry gangrene

44
Q

Classification PAD: Claudication

A

WIFI classification - Wound, Ischemia, Foot Infection = lower extremity threatened limb loss classification system to assess risk for amputation risk w/in 1 year

45
Q

Dx PAD: Claudication -

3 techniques/options & 5 essentials for dx

A

ABI:

  • Ankle SBP/brachial SBP
  • Normally Ankle SBP > brachial SBP
  • Arterial dz = lowers lower ext BP, level lower is proportional to disease severity

Arterial duplex US:
- assesses pulses/bl flow in arteries

CTA/MRI:
- helps to localize where artery blockage is

Essentials for diagnosis:
[1] ischemic rest pain [2] tissue loss [3] ABI < 0.9, [4] abnormal pulse pressure, [5] claudication

46
Q

Treatment PAD: Claudication

A

Conservative: modify RF, smoking cessation, consistent moderate exercise

Medical: ASA & Statin +/- cilostazole (minimizes platelet clotting, improves walking distance)

Surgery:
Revascularization - angioplasty, stent, endarectomy, open bypass

47
Q

Indications for surgical intervention: PAD: Claudication

A

Disabling claudication, ischemic rest pain, ulceration, gangrene

48
Q

Types of surgical interventions PAD: Claudication - how to decide based on classification

A

Surgical revascularization options:
Angioplasty, stent, endarterectomy, surgical open bypass

Use TASC classification to determine percutaneous vs open surgery

A/B lesions - less severe - percutaneous

C/D lesions - more severe - require open surgery (endarterectomy or bypass)

Surgery EORE (3 decks)

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